5.2 Strategies

Strategies for dealing with specific behaviour changes following TBI

If you have completed Module 4
Go direct to 5.3 Analysing problem behaviourwith a view to management
as you will have already covered
5.1 Changes following TBI
in Module 4.3 and
5.2 Strategies for dealing with cognitive changes
in Module 4.4

i) Management strategies

As you saw in the brainstorm activities at the end of the previous section, each cognitive deficit (eg a deficit in flexibility) will result in a person facing particular problems (eg being unable to adapt to change). There are management strategies that you and others working with the person can use to assist in minimising the impact of these deficits.

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iii) Changes, problems and strategies

Another example is shown in the following table:

Cognitive and behavioural changes

       Problems arising

     Management strategies

Speed of information processing

  • taking longer to complete tasks
  • unable to keep track of lengthy conversations and instructions
  • make allowances and give the person extra time
  • present information slowly
  • present information in chunks
  • present one thing at a time
  • check that the person is keeping up

 

 

FULL LIST: Changes, problems arising, management strategies

 

Cognitive and behavioural changes

       Problems arising

     Management strategies

Attention and Concentration

  • have difficulty concentrating
  • being distractible
  • finding it hard to cope with more than one thing at once
  • getting bored quickly
  • switch off and appear not to listen
  • not remembering what others have said
  • not completing things they start
  • changing the subject often
  • reduce distractions (e.g. noise, other people)
  • use short, simple sentences
  • encourage the person to stay with the activity for longer periods
  • change activities when necessary
  • when distracted, interrupt and bring back to task
  • give reminders of next step
  • keep to a routine

Speed of information processing

  • taking longer to complete tasks
  • unable to keep track of lengthy conversations and instructions
  • make allowances and give the person extra time
  • present information slowly
  • present information in chunks
  • present one thing at a time
  • check that the person is keeping up

Fatigue

  • having an overall reduced ability to cope
  • getting irritable and distressed
  • having other problems exacerbated
  • encourage the person to take rest breaks
  • schedule more demanding tasks when the person is at their best (often mornings)

Memory

  • finding it hard to remember new things
  • forgetting appointments
  • forgetting things people say
  • frequently losing things
  • give reminders
  • repeat information when necessary
  • encourage person to rehearse and repeat information
  • encourage use of external reminders, i.e. diaries, post-it notes
  • structure a routine by breaking tasks into small steps
  • keep belongings in regular places

Problem solving

  • reduced ability to find solutions to problems
  • train the person to approach new tasks in a systematic manner, e.g. break the task into small parts
  • reduce the demands made on the person
  • help educate the family and others about the person's problems
  • avoid giving the person open-ended tasks

Planning and
organisation

  • having difficulty working out the steps involved in a task
  • not considering the end result of their actions
  • having trouble organising their thoughts and explaining things to others
  • avoid becoming frustrated with the person
  • give prompts for the following steps
  • provide a written list which outlines the steps in order

Rigid and
concrete thinking

  • taking statements literally
  • insensitive and unable to consider feelings of others
  • having a simplistic understanding of emotions
  • being resistant to change
  • keeping doing things incorrectly despite feedback
  • use simple and direct language, avoid abstract terms
  • avoid using hints or sarcastic humour
  • encourage person to imagine how they would feel in other situations
  • explain any change in routine in advance, giving reasons

Disinhibition

  • being impulsive and act without thinking of consequences
  • making rash decisions
  • acting inappropriately toward people (including sexually)
  • behaving in a silly, flippant or childish way
  • disclosing personal information too freely
  • give immediate feedback, briefly
    asking person to stop behaviour
    and explain why
  • provide appropriate external
    controls e.g. over finances
  • remind person of the sensitive
    nature of some information,
    giving clear examples
  • ignore the behaviour where
    possible

Reduced self-control

  • losing temper quickly
  • being physically/verbally abusive
  • having a lower frustration tolerance
  • distract or remove the person from anger-provoking situation
  • withdraw attention when appropriate
  • try not to escalate the situation by shouting back
  • identify anger-provoking triggers and avoid when possible

Egocentricity and
self-absorption

  • not considering consequences of their behaviour on others
  • being unable to 'put themselves in someone else's shoes'
  • appearing selfish to others
  • not appreciating carers
  • try to explain situation from another's or your point of view
  • try not to take offence, understand why the person is like that

Emotional lability

  • laughing and crying inappropriately
  • changing moods quickly
  • try to identify triggers which result in mood swings
  • be prepared for changes by having alternative plans

Perseveration

  • talking about the same topic repeatedly
  • returning to the preferred topic when doing something else
  • remind person gently they've told you the information before
  • distract the person back to the preferred activity
  • ignore, as much as possible, future references to the topic
  • try not to get into arguments, walk away if you're getting irritated

Reduced insight

  • being unaware of both cognitive and physical limitations
  • having unrealistic goals, plans and expectations
  • resisting efforts of carer/staff
  • not realising that they have made errors because they haven't checked their work
  • gently remind person of deficits
  • explain why proposed action is useful, reason through the steps
  • point out possible negative consequences of person's unrealistic plans
  • place external limitations where necessary (e.g. removal of driver's licence/access to car)
  • gradually expose person to reality testing experiences

Poor self monitoring

  • not realising that they are 'hogging' conversations
  • being verbose and keep talking when others are no longer interested
  • encourage them to check over their work
  • use signals, agreed in advance, to let them know they're talking too much
  • encourage turn-taking in conversation
  • use external aids, e.g. graphs and tables to help the person monitor their behaviour

Reduced social
skills

  • interacting poorly with others because of all the above problems
  • losing their ability to relate well with others
  • not picking up the usual social cues (e.g. looking at watch)
  • teach specific strategies like maintaining eye contact, asking questions of others, turn taking in conversation
  • try to encourage awareness of others' reactions

Inertia

  • appearing to have no motivation and seem apathetic
  • not acting until prompted
  • not completing tasks
  • knowing how to do something, but not doing it spontaneously
  • encourage person to commence activity
  • prompt first step of the task
  • try to find things that are most interesting for the person
  • reward and encourage any self-initiated activity and persistence
  • accept that the person may need less activity to keep them occupied and happy

Restlessness

  • complaining of boredom and be
    restless and agitated
  • remind person of activities they usually enjoy
  • promote physical activity which may expend some energy